I wanted to reach out to see if anyone has had a potential solution (even if not perfect) to certain medications not being missed. Obviously all medications are important, but some have more serious consequences that others when missed. This is often complicated by the fact that sometimes the medications are missed due to patient being off the floor, unavailability of the medication on the floor, etc.

Medications that we are particularly thinking of include but are not limited to:

Hi everyone,

I have had some questions regarding etoposide precipitation when a peristaltic pump is used to infuse this drug. However, from what I can find in the literature the language is soft, i.e. "non-peristaltic pump preferred" or "peristaltic pump MAY increase drug precipitation".

I'm wondering if anyone has encountered this previously? If you use a peristaltic type pump institution wide, would you change to a different pump specifically for etoposide? Also helpful to know if you do use this pump type for etoposide with no issues.

Good Afternoon-

Our organization is looking at increasing the role of pharmacists in the assessment of polypharmacy and specifically to start looking prospectively at the medications upon admission that may contribute to falls. Does anyone has a vetted pharmacy specific tool that they can share and has anyone leveraged the EMR to assist with identifying these patients. We have EPIC as our EMR.

Thank you for any information that you can share.

Natalie Zilban

Does anyone have a protocol for using flush bags to ensure the entire volume of a primary parenteral infusion goes into the patient? Our primary sets have a volume of ~24 mL and when an intermittent completely "infuses" there is still a somewhat large volume of drug left in the tubing. My understanding from our pump vendor is that the only way to address this is either use of a flush bag or by hanging the intermittent into a secondary line.

Hi everyone -

For those of you that have responsibility over outpatient/retail pharmacies, do you have any balancing safety metrics against productivity, that you could share? Thanks in advance for anything you may have!

We are working on improving Press Ganey scores for the medication domain. The survey questions are listed below.
We have been working on side effect education.

Please share any projects that you have worked on to improve scores at your institutions.

•Question 13 asks “before giving you any new med, how often did hospital staff tell you what the med was for?”

•Question 14 asks about side effects

Hi,

If your smart pumps and EMR are integrated, could you please respond to the questions below?

1. What was your initial goal of compliance with the use of interoperability (%)?

2. What is your current goal?

3. Does your interoperability compliance data incorporate (1) no attempts AND (2) failed attempts?

4. How long have you had smart pump and EMR interoperability?

5. What is your pump brand?

6. Who is your EMR provider?

Thank you so much in advance!
Viktoriya

Hi,

If your smart pumps and EMR are integrated, could you please respond to the questions below?

1. What was your initial goal of compliance with the use of interoperability (%)?

2. What is your current goal?

3. Does your interoperability compliance data incorporate (1) no attempts AND (2) failed attempts?

4. How long have you had smart pump and EMR interoperability?

5. What is your pump brand?

6. Who is your EMR provider?

Thank you so much in advance!
Viktoriya

ISMP has received reports from two different hospitals about McKesson packaged levetiracetam 250 unit dose blister packages that have a barcode that scans as naproxen 500 mg. Apparently one side of the unit dose blister of 10 levetiracetam tablets scans properly, but the barcode on other side indicates that the blister contains naproxen 500 mg. The NDC number is 63739-795-10. The lot number in both cases is 0000124916.

Based on visual inspection of the tablet and imprint code, the tablets contained in the blister pack all appear to be levetiracetam 250 mg.

What do you all do create awareness of twins, triplets, etc. for the sterile compounding staff? We have had issues with medication mixups due to similar names and identical birth dates.
Thanks -
Maria Cumpston, PharmD, CPPS
Medication Safety Officer
WVU Medicine